Embracing the Financial Counseling Role

Revenue cycle teams boost their effort to engage patients financially.

This article first appeared in the December 2016 issue of HealthLeaders magazine.

Laurie Hurwitz is on a mission to revolutionize revenue cycle operations at Gundersen Health System and encourage other healthcare providers to align the bill collection process with a patient-centric approach to medicine.

Over the past three years, Hurwitz, the executive director of revenue cycle at the La Crosse, Wisconsin-based health system, has helped several initiatives that are designed to improve the nonprofit organization's financial engagement capabilities with patients, including the creation of a 17-member financial counseling staff. These initiatives have increased the up-front collection bill payments from patients, but that gain for Gundersen pales in significance compared to achieving fundamental change in the financial relationship between patients and the healthcare system, Hurwitz says.

"The fact that we weren't asking for money before is far less troubling than the fact that we weren't telling patients that something was going to cost them."

"To me, this isn't about increasing point-of-service collections. This is about making sure our patients are fully informed with all of the information that they need to make critical decisions. The fact that we weren't asking for money before is far less troubling than the fact that we weren't telling patients that something was going to cost them before they had it done. That's a very uncomfortable thing for people in healthcare to think about because we say that we don't want a patient deciding against having care because of what something costs; but the truth is, patients have the right to make that decision, and it is our responsibility to see to it that they have the information to make the decision that is right for them and right for their families."

Gundersen's financial counselors are playing a crucial role for patients, she says. "It is also incumbent on us to make sure patients understand there are resources out there that we can help them find. Everything from Medicaid to our own internal financial assistance program. It's not fair for patients to go through some of the very challenging medical treatments that they have to go through and their journey to get well while being worried about what it's going to cost when the bill shows up. And that's what everybody does."

The practice of hiring staff members to play a financial engagement role with patients is so new that health systems and hospitals are trying to figure out the best title for the position. "We have gone back and forth on what the right term is. We call them financial counselors now, but we have talked about whether that is the right title or financial advocate is better," Hurwitz says.

As the Consumer Age dawns in the healthcare industry, revenue cycle teams at health systems and hospitals across the country are employing staff members to play a financial engagement role for patients who struggle to pay their bills, particularly for inpatient hospital services.

"Our best practice is to meet with all patients who have a financial responsibility, so that we can take a payment or establish a financial assistance plan as early as possible."

At St. Francis Hospital in Columbus, Georgia, hospital registration staff have been providing financial counseling services for years, says Linda Glass, director of patient access services. However, the 376-licensed-bed acute care facility created and staffed a full-time "benefits advisor" position in July to help patients navigate their financial obligations at any time during their hospital stay, she says.

"We train all registration staff in all areas except ER on what all the processes are, so they can assist patients at all times," Glass says of financial counseling at St. Francis. "We have one employee called a benefits advisor who goes to the floors to discuss more in-depth with inpatients, especially those coming from the ER. We do not feel like doing this in the ER is of much benefit due to the situation, timing, and flow of patients. We are set to see 70,000 patients through the ER this year, and 65% of admissions come from this area. The benefits advisor goes to the floors and can spend more time with patients in a less stressful area or situation like in the ER."

At St. Francis, revenue cycle staff members who provide financial counseling to patients need to know the financial resources that are available and the procedures to access those resources, but that is not the most important capability to succeed in the role, Glass says. "A good financial advisor is someone who understands and can explain insurance benefits and all the different programs the hospital has from financial assistance, payment plans, and the company we use to apply for Medicaid assistance. The most important piece is they must have good customer service skills and not get easily upset. To go in and discuss with patient or family while someone is in the hospital how much money they owe is not always a good experience. Some patients and family members will be upset that you are going to ask for money while their loved one is sick. … The advisors need to have the ability to explain that they are there to assist the patient so we can get any type of programs or assistance started early and not when all the bills start arriving after they get home."

Starting the financial-engagement process with patients as early as possible is a top priority for the St. Francis revenue cycle team because timeliness benefits both the patients and the hospital, Glass says. "A lot of patients want to hear what they might owe and are willing to work with us. Our best practice is to meet with all patients who have a financial responsibility, so that we can take a payment or establish a financial assistance plan as early as possible. If not, we will be months down the road before this is set up and payments start coming in."

At Gundersen, the best practices of financial counselors are focused on informing patients about the resources that are available to help pay for medical bills, Hurwitz says. "We do not provide financial advice to patients. We help explain insurance benefits to patients because most people do not understand them—we see that as our responsibility to educate them. We provide patients with information about resources that can help them with their financial obligations. We provide them with estimates, both the total charges and their out-of-pocket responsibility. So, we're providing them with resources and information; we are not providing them with advice."

The Gundersen financial counselors are expected to possess or develop a relatively advanced skill set, says Shannon Carey, manager of revenue cycle at the health system, which is centered on 325-licensed-bed Gundersen Lutheran Medical Center in La Crosse. "One of the most important things I look for is outstanding communication skills, verbally and in writing. I also look for good deescalation skills. ... After patients get their bills, the financial counselors need to be able to deescalate situations and give information to the patients to make sure they understand. We try to do more behavioral interviewing to get people with these kinds of exceptional skills."

The financial counselors also need specialized business skills to function effectively, Carey says. "They have to have good computer skills, too. We have multiple systems that they have to be fluent in for giving good service here. Mostly, they're in an office without a group around them, so they need to have a strong independent work ethic and be able to be independent thinkers. There's a lot of attention to detail and follow-up work. We can't always give answers to questions at the time the patient is present—we may have to wait for information from an insurance company or the county. They have to have a basic knowledge of coding and medical terminology; especially when they are trying to give patients estimates, they need to understand if there are missing codes or what might be entailed in a procedure that a patient could be billed for. When patients run into denials, the financial counselors have to have an understanding of insurance rules and coding rules. We don't require them to be coders, but they have to have a general understanding. And they have to be able to handle money and balance cash drawers because they are taking payments."

Convincing a health system's leadership team to embrace creating a financial counselor job title and finding suitable candidates to fill the role can be daunting, some financial leaders say.

"It's challenging, that's for sure," Hurwitz says. "Health systems have a lot of layers and processes. Whenever you try to do something new and different, it's very difficult to find out where the new thing fits into the old scheme. We're still trying to work our way through that. We've made progress; not as much as we would like. It's an enormous challenge—Shannon's description of a financial counselor is a superhero."

Not surprisingly, there are precious few healthcare financial-counseling superheroes looking for work in the job market, Carey says. "We have to train them when they come here. In addition to good computer knowledge, the skill that we look at mostly is the communication piece. Are they going to be a good face-to-face representative who is able to comfort people and get them through difficult times? That's something that we can't train necessarily. Other things, like being able to quote insurance, can be trained once a new financial counselor gets here."

Pinpointing the financial impact of Gundersen's financial counselors and the other patient financial-engagement initiatives that the health system has launched over the past three years is difficult, but Carey and Hurwitz are convinced the efforts are having a positive effect on the bottom line.

Part of the difficulty of gauging the bill-collection impact of Gundersen's financial counselors is the absence of a historical baseline because the health system only began asking patients for money up front when the counselor roles were filled three years ago, Carey says. "Part of what our counselors do is preregister all of our surgical patients, and they give patients an estimate of what the entire procedure will cost and the out-of-pocket costs; then we ask for that up front. Prior to having the financial counselor role, we didn't ask for that money up front at all, so any payments we are collecting before the service is provided are new and a benefit to the organization."

A key measure of the financial impact of the counselors and other patient financial-engagement initiatives at Gundersen is the cost to collect medical bills, Hurwitz says. "While we have added these services, we have not increased our cost to collect. We've done a lot of things that are patient-facing, but we have not increased our cost to collect; we have actually reduced it a little bit. It's not a whole lot different from what's been going on in manufacturing for years. If you can do things right from the beginning, you have a whole lot less work on the back end, and the work on the back end is more expensive. It's much harder to fix something than it is to prevent something."